Dermatology

Item: 1 of 7 ~ 1 • Mark -<] C> Jill ~· ~J
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• 1
A 30-year-old woman comes to her primary ca re physician complaining of bright red blood in her stool. She also complains !•Aj
of increased urgency w ith bowel movements in the past 6 months and has had two occasions recently when she was not A
able to reach the bath room in t ime . On physical examination, vital signs were within normal lim its except her heart rate,
•4 which was 105/min . Laboratory evaluation reveals a hemoglobin of 10 g/d L, leukocyte count 15,000/microL. She was referred
for endoscopy with biopsy which reveals mucosal and submucosal inflammation. The affected t issue is lim ited to the rectum .
Which of the following skin conditions is associated with this patient's gastrointestinal disease'
A. Macu les, papules, vesicles, and targetoid lesions

B. Multiple shallow erosions covered with dried serum and oral mucosal erosions
C. Pruritic eruptions of erythematous papules and plaques on flexor surfaces
D. Slightly raised, tender, erythematous nodules 1-5 em in diameter on the anterior legs
E. Tense bullae filled with clear fluid
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•3
The correct answer is D. 590/o chose this .
•4
The patient is suffering from an active flar e of ulcerative colitis (UC) . Extraintestinal manifestations of UC include erythema
nodosum (EN ), pyoderma gangrenosum, primary scleros ing cholangit is, uveitis, and arthritis. EN is the most common
cutaneous disorder associated with both UC and Crohn disease. EN generally presents as raised, tender, erythematous
nodules 1-5 em in diameter. As shown in the image above, the nodu les are most frequently foun d on extensor surfaces,
especially the anterior tibial area . EN typically is exacerbated during episodic flares of inflammatory bowel disease (IBD).
Primary sderosing cholangitis Pyoderma gangrenosum Ulcerative colitis Inflammatory bowel disease Erythema nodosum Uveitis Crohn's disease Erythema Colitis Arthritis
Cutaneous condition Gastrointestinal tract Ascending cholangitis Pyoderma
A is not correct. 8% chose this.

Erythema multiforme is associated with infectious disorders, certain drugs (ie, sulfonam ides), malignancies, and some
collagen vascula r diseases . It is not generally consider ed a manifestation of inflammatory bowel disease. As the name
implies, this condition is manifested by multiple types of lesions, including macules, papu les, vesicles, and target lesions.
Erythema multiforme Inflammatory bowel disease Collagen Erythema Sulfonamide (medicine) Cancer Autoimmune disease Sulfonamide Cutaneous condition Papule Malignancy
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1 Cutaneous condition Gastrointestinal tract Ascending cholangitis Pyoderma

•2
•3
Erythema multiforme is associated with infectious disorders, certain drugs (ie, sulfonam ides), malignancies, and some
•4
collagen vascular diseases . It is not genera lly considered a manifestation of inflammatory bowel disease. As the name
implies, this condition is manifested by multiple types of lesions, including macules, papu les, vesicles, and target lesions.
Erythema multiforme Inflammatory bowel disease Collagen Erythema Sulfonamide (medicine) Cancer Autoimmune disease Sulfonamide Cutaneous condition Papule Malignancy
Infection Blood vessel Gastrointestinal tract
B is not correct. 150/o chose this.

Pemphigus vulgaris is a rare autoimmune skin disorder in w hich autoantibodies are directed against desmogleins of mucous
membranes, resu lt ing in the breakdown of epithelia l cell-to-cell junctions (acantholysis) . Patients present with intradermal
bullae involving the oral mucosa and skin. These lesions rupture easily, resulting in shallow erosions covered w ith dried serum
and crusts . Pemphigus vulgaris does not have a sign ificant association with inflammatory bowel disease.
Pemphigus vulgaris Acantholysis Inflammatory bowel disease Pemphigus Autoantibody Mucous membrane Epithelium Blister Autoimmune disease Cutaneous condition Autoimmunity
Desmoglein Oral mucosa Serum (blood) Gastrointestinal tract Inflammation
C is not correct. 150/o chose this.

Atopic dermatitis, also known as eczema, is characterized by pruritic eruptions of erythematous papules and plaques on f lexor
surfaces . This dermatologic cond it ion is often associated with other atopic diseases (asthma, hay fever, and allergic rhinitis),
but not inflammatory bowel disease.
Atopic dermatitis Dermatitis Inflammatory bowel disease Allergic rhinitis Asthma Atopy Itch Rhinitis Erythema Papule Gastrointestinal tract Fever Dermatology Hay Allergy
E is not correct. 30/o chose this.

Bu llous pemphigoid is an autoimmune disorder in which autoantibodies are directed against epidermal basement membrane.
Clin ically the lesions present as tense bu llae fi lled with dear fluid . The bullae do not rupture as easily as the blisters seen in
pemphigus vulgaris, and the oral mucosa is usually spared . Bu llous pemphigoid does not have a significant association with
inflammatory bowel disease .
Bullous pemphigoid Pemphigus Pemphigus vulgaris Autoimmune disease Inflammatory bowel disease Basement membrane Autoantibody Cutaneous condition Autoimmunity Blister
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1 and crusts . Pemphigus vulgaris does not have a sign ificant association with inflammatory bowel disease.
•2 Pemphigus vulgaris Acantholysis Inflammatory bowel disease Pemphigus Autoantibody Mucous membrane Epithelium Blister Autoimmune disease Cutaneous condition Autoimmunity
•3 Desmoglein Oral mucosa Serum (blood) Gastrointestinal tract Inflammation
•4 C is not correct. 150/o chose this.

Atopic dermatitis, also known as eczema, is characterized by pruritic eruptions of erythematous papules and plaques on f lexor
surfaces . This dermatologic cond it ion is often associated with other atopic diseases (asthma, hay fever, and allergic rhinitis),
but not inflammatory bowel disease.
Atopic dermatitis Dermatitis Inflammatory bowel disease Allergic rhinitis Asthma Atopy Itch Rhinitis Erythema Papule Gastrointestinal tract Fever Dermatology Hay Allergy

Bu llous pemph igoid is an autoimmune disorder in which autoantibodies are directed against epidermal basement membrane.
Clin ically the lesions present as tense bu llae filled with dear flu id . The bullae do not ruptu re as easily as the blisters seen in
pemphigus vulgaris, and the oral mucosa is usually spared . Bu llous pemphigoid does not have a significant association with
inflammatory bowel disease .
Bullous pemphigoid Pemphigus Pemphigus vulgaris Autoimmune disease Inflammatory bowel disease Basement membrane Autoantibody Cutaneous condition Autoimmunity Blister
Mucous membrane Oral mucosa Epidermis Pemphigoid Gastrointestinal tract Inflammation
Bottom line:
Extraintestinal manifestations of ulcerative colitis include erythema nodosum, pyoderma gangrenosum, primary sclerosing
cholangitis, uveitis, and arth ritis.
Primary sclerosing cholangitis Pyoderma gangrenosum Ulcerative colitis Erythema nodosum Uveitis Erythema Colitis Arthritis
References:
FA Step 2 CK 9th ed p 60
FA Step 2 CK 8th ed pp 45; 138
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A 19-year-old woman comes to the physician complaining of a pruritic rash on her ankle. She recently retu rned from a ~~AI
•2
camping trip. Physical examination revea ls a linear arrangement of weeping vesicles with surrounding erythema
•3 encompassing a 5-cm 2 area on her right ankle. There are secondary excoriations around the rash . The rest of the physical
•4 examination is normal. A pictu re of another patient with the same condition is shown .
Which of the following is the most appropriate treatment?
A. Oral acyclovir
B. Oral corticosteroids
C. Oral dicloxacillin
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Which of the following is the most appropriate treatment?
A. Oral acyclovir
B . Oral corticosteroids
C. Oral dicloxacillin
D . Topical antifungal
E. Topical corticosteroids
a
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2 The correct answer is E. 73% chose this.

•3 This patient has a rash consistent with contact dermatitis and was likely exposed to poison ivy or poison oak during her
•4
recent camping trip. The nature of the rash and the distribution in a linear arrangement localized to the area of contact are
characteristic of contact dermatitis . The linear arrangement is secondary to scratching as the urushiol (the allergen in
Toxicodendron spp.) is spread by the patient from the site of init ial contact to surrounding areas. Secondary excoriations are
typically seen . Mild cases can be t reated with cool compresses or an oatmeal preparation and topical steroids 3-4 t imes a day
to reduce pruritus. Severe reactions, rashes involving the face and airway, or widespread areas of involvement may warrant
oral corticosteroids; however, this patient's rash is limited to a 5-cm 2 area on her lower extrem ity.
Urushiol Toxicodendron radicans Contact dermatitis Toxicodendron diversilobum Allergen Itch Corticosteroid Dermatitis Toxicodendron Oatmeal Rash Respiratory tract Topical steroid
Poison Oak
A is not correct. SOfo chose this.

Oral acyclovir is used to treat herpes virus types 1 and 2 infections. These infections are typically seen in the oral or gen ital
regions . The rash of herpes is typically clear vesicles on an erythematous base, similar to this patient's rash . However, given
the location and recent camping trip, it is much more likely that this patient's rash is due to contact dermatitis .
Aciclovir Contact dermatitis Herpesviridae Herpes simplex virus Herpes simplex Dermatitis Erythema Virus Vesicle (biology and chemistry) Rash Infection

Systemic corticosteroids tapered over a period of 21 days may be required in severe cases of contact dermatitis, including
involvement of the face or gen ital area or inha lational contact dermatit is from burning plants that contain urushiol. The most
common mistake in the management of severe plant dermatit is is prescribing a 6-day course of corticosteroids such as those
found in "dose packs." The patients will invariably rebound once the 6-day course is completed.
Urushiol Contact dermatitis Corticosteroid Dermatitis Sex organ
C is not correct. SOfo chose this.

Oral dicloxacillin is used to treat skin infections ( such as cellulit is and impetigo) due to Staphylococcus aureus and P-
hemolytic streptococci (primarily group A) . Ora l antibiotics are not necessary in this case; however, if secondary bacterial
infection is suspected, appropriate systemic antibiotics (typically directed at gram-positive organisms) should be
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common mistake in the management of severe plant dermatit is is prescribing a 6-day course of corticosteroids such as those
2
found in "dose packs." The patients will invariably rebound once the 6-day course is completed .
•3 Urushiol Contact dermatitis Corticosteroid Dermatitis Sex organ
•4
C is not correct. SOfo chose this.
Oral dicloxacillin is used to treat skin infections ( such as cellulit is and impet igo) due to Staphylococcus aureus and ~
hemolytic streptococci (primarily group A) . Oral antibiotics are not necessa ry in this case; however, if secondary bacterial
infection is suspected, appropriate systemic antibiotics (typically directed at gram-positive or ganisms) should be
administered .
Dicloxacillin Impetigo Cellulitis Streptococcus Staphylococcus aureus Gram-positive bacteria Antibiotics Pathogenic bacteria Staphylococcus
D is not correct. 4% chose this.

Topical antifungal cream is used to treat t inea corporis and other fungal infections of the skin. These infections would not be
characterized by weeping vesicles. Rather, they ar e prurit ic, ring-shaped scaling plaques that often have central clearing .
Tinea corporis Fungicide Itch Antifungal Mycosis Tinea Fungus Vesicle (biology and chemistry)
Bottom line:
Treat mild cases of contact dermatitis with cool compr esses or an oatmeal preparation and topical steroids . Severe cases of
contact dermatit is require a 21-day cour se of cort icosteroids; the most common mistake in the management of these
patients is to prescribe a "dose pack" which provides only a 6-day cour se and invariably results in rebound contact
dermatitis.
Contact dermatitis Corticosteroid Dermatitis Oatmeal Steroid Topical steroid
References:
FA Step 2 CK 9th ed pp 51-54
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A 64-year old fisherman comes to his primary care physician for his annual examination . He has no complaints other than
2 a sca ly lesion on his right temple. He reports that he has had a "red spot" in the same location for about a year, but
•3 recently he has noticed occasional slough ing of skin . The lesion is not painful. Physical examination reveals a 0.5- x 0.5-
•4 cm rough, scaly, erythematous patch. Biopsy revea ls parakeratosis and dysplastic keratinocytes that are clearly con fined to the
lower layers of the epiderm is.
Which of the following is the most likely diagnosis?
A. Actinic keratosis
B. Basal cell carcinoma
C. Melanoma
D. Seborrheic keratosis
E. Squamous cell ca rcinoma
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The correct answer is A. 590/o chose this .
•4
Actinic keratoses (AK) are premal ignant lesions that form on sun-damaged skin. AK is most common on the face, scalp, ears,
and forearms. AK is an evolving carcinoma in situ, and whi le most AKs do not progress to squamous cell carcinoma (SCC),
the majority of sec arises from AK. AKs are classica lly described as small ( < 1 em in diameter), erythematous, sca ly papules
that usua lly have a spine-like or sandpaper texture. On histologic examination AK is characterized by cytologic atypia in the
lowermost reg ion of the epidermis and parakeratosis . Lesions that progress to full-thickness (referrin g to the fu ll thickness of
the epidermis) atypia are referred to as sec in situ. The most common treatments for AK include liquid nitrogen cryotherapy,
5-fluorouracil cream, and surgical excision .
Fluorouracil Actinic keratosis Squamous-cell carcinoma Liquid nitrogen Cryotherapy Parakeratosis Epidermis Carcinoma in situ Skin cancer Histology Erythema Precancerous condition
Actinic elastosis Carcinoma Scalp Papule Squamous epithelial cell Sandpaper

Basal cell carcinoma (BCC) is the most common type of skin cancer. BCC is most common in sun-exposed areas of the body,
and rarely if ever metastasizes . The lesions are generally described as pearly, smooth-surfaced papu les with associated
telangiectat ic vessels. Advanced lesions may ulcerate . Cytologically, tumor cells typica lly grow as islands or nodular lesions
w ithin the dermis. The cells forming the periphery of the tumor islands are arranged radial ly with their axes having paral lel
alignment (palisad ing).
Basal-cell carcinoma Dermis Skin cancer Metastasis Cytopathology Cancer Carcinoma Neoplasm Telangiectasia Ulcer (dermatology) Papule Stratum basale Nodule (medicine)
C is not correct. 3% chose this.

Of all skin cancers, melanoma carries the greatest risk of metastasis. Like sec and BCC, ma lignant melanoma is associated
with sun light exposure, especially in fair-skinned patients . The most important clinical sign of the disease is a change in the
color, size, symmetry, or pigmentation of a pigmented lesion or nevus. Histologically, the depth of malignant melanoma cells
correlates with the risk of metastasis.
Melanoma Medical sign Metastasis Histology lesion Cancer Malignancy Pigment Nevus
D is not correct. 100/o chose this.
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color, size, symmetry, or pigmentation of a pigmented lesion or nevus. Histologically, the depth of malignant melanoma cells
2 correlates with the risk of metastasis.
3 Melanoma Medical sign Metastasis Histology lesion Cancer Malignancy Pigment Nevus
•4 D is not correct. 100/o chose this .

Seborrheic keratosis is typically described as waxy, smooth, or soft in texture and they are not associated w ith an
erythematous base, nor are they only found on sun-exposed areas .
Seborrheic keratosis Erythema Keratosis
E is not correct. 16% c hos e this .

sec is the second most common type of skin cancer in t he United States, after BCC . Although it is locally invasive, it rarely
metastasizes and excisional therapy is curative. sec usually appears as an indurated or firm papule with hyperkeratosis
and/ or ulceration . Un like AK, sec is characterized by highly atypical cells at all levels of the epidermis and accumulations of
keratin (keratin pearls) are common. If histopathology reveals atypical keratinocytes present in the dermis or deeper,
suggesting penetration of the epidermal basement membrane, sec is considered invasive.
Papule Keratin Dermis Basement membrane Hyperkeratosis Histopathology Epidermis Skin cancer Ulcer (dermatology) Cutaneous condition Ulcer Keratinocyte Cancer Mouth ulcer
Metastasis United States
Bottom line :
Actinic keratoses are premalignant lesions on sun-damaged areas of skin . They are classically described as small ( < 1 em in
diameter), erythematous, scaly papules that usually hav e a spine-like or sandpaper texture .
Actinic keratosis Skin cancer Erythema Precancerous condition Sandpaper Papule Actinism
Refere n ces:
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A 35-year-old woman comes to her primary ca re physician complaining of burning w ith urination and increased urinary ~~AI
2 frequency over the past 4 days. The patient denies hematuria, nocturia, and back pain. Her last menstrual period was 3
3 weeks ago . Urinalysis is positive for leukocyte esterase and nitrite, and the patient is prescribed an antibiotic. A week later
•4 the patient returns complaining of a fever and a rash. She notes that her fever started a couple days before she developed a
rash on her face, which then spread to her trunk . Her blood pressure is 120/80 mm Hg, pulse is 120/min, r espiratory rate is
20/min, and temperature is 39°C ( 102.2°F) . Physical examination reveals a diffuse, tender rash with poorly defined
erythematous macu les and numerous target-like lesions involving <10% of her body surface area . She also has pa inful
hemorrhagic crusting on her lips .
What is the most likely cause of this patient's presentation?
A. Exfoliative dermatitis
B. Scalded skin syndrome

C. Stevens-Johnson syndrome
D. Toxic epidermal necrolysis
E. Toxic shock syndrome
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2 The correct answer is C. 730/o chose this.

3 This patient presents with Stevens-Johnson syndrome (SJS) secondary to treatment for acute cystitis. SJS is a type of
4 erythema mu ltiforme that is genera lly preceded by a prodrome (fever and influenza-like symptoms) 1-3 days before the
•5 onset of mucocutaneous lesions . In addition to the characteristic rash described, patients with SJS may have pa lpable
purpu ra, skin necrosis, bul la formation, and sloughing of the skin. SJS is most commonly caused by r eaction to medication .
•6
Some drugs, but not all, that are common ly implicated include al lopurinol, su lfonamides, antiepileptic agents ( ie,
•7 carbamazepine, lamotrigine, ethosuximide, and phenobarbital), and some nonsteroidal anti-inflammatory drugs ( especially
piroxicam) . This patient initia lly presented w ith a urinary tract infection, and her primary car e physician likely prescribed
trimethoprim-su lfamethoxazole (TMP-SMX), w hich is a su lfonam ide notorious for inducing drug reaction . Other adverse
effects of TMP-SMX include mega loblastic anemia, leukopenia, nephrotoxicity, and hemolysis in glucose-6-phosphate
dehydrogenase deficient patients. Her presentation involving < 10 percent of her body surface area is consistent with the
diagnosis of SJS.
Urinary tract infection Ethosuximide Stevens-Johnson syndrome Carbamazepine Lamotrigine Sulfonamide (medicine) Phenobarbital Allopurinol Leukopenia Erythema multiforme
Megaloblastic anemia Trimethoprim/sulfamethoxazole Nephrotoxicity Erythema Sulfonamide Prodrome Anticonvulsant Piroxicam Hemolysis Anemia Necrosis
Nonsteroidal anti-inflammatory drug Rash Anti-inflammatory Urinary system Fever Pharmaceutical drug Puroura

Exfoliative dermatitis is a scaly dermatitis involving almost all of the body's skin . It can occur secondary to treatment with
new medications, underlying systemic diseases, or idiopathic cause. Constitutional symptoms such as fever and malaise ar e
common. Although an important differential, the presence of a targetoid rash indicates a more likely diagnosis.
Erythroderma Malaise Dermatitis Rash Idiopathy Fever

Staphylococcal sca lded skin syndrome (SSSS) is caused by an initia l infection of staphylococcal-producing exfoliative toxins
that results in diffuse, erythematous rash and bu llae that rupture easily and leave the skin looking like a burn . This infection
is commonly seen in children, especially newborns, and is less likely the cause of this patient's presentation.
Staphylococcal scalded skin syndrome Erythema Blister Cutaneous condition Staphylococcus Rash
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T •• - o o o • ... o o • ••• T "T"
2 B is not correct. 6 0/o chose this.

3 Staphylococcal sca lded skin syndrome (SSSS) is caused by an init ial infection of staphylococcal-producing exfoliative toxins
that resu lts in diffuse, erythematous rash and bu llae that rupture easily and leave the skin looking like a burn . This infection
4
is commonly seen in children, especially newborns, and is less likely the cause of th is patient's presentation .
•5 Staphylococcal scalded skin syndrome Erythema Blister Cutaneous condition Staphylococcus Rash
•6
Dis not correct. 110/o chose this .
•7
Toxic epidermal necrolysis (TEN) is a type of erythema mu lt iforme that is genera lly preceded by a prodrome (fever and
influenza-like symptoms) 1- 3 days before the onset of m ucocutaneous lesions. In add it ion to the characteristic rash
described, patients with SJS may have pa lpable purpura, skin necrosis, bu lla formation, and sloughing of the skin. TN is most
common ly caused by a reaction to medication . Some drugs, but not all, that are commonly implicated include allopurinol,
su lfonam ides, antiepileptic agents ( ie, carbamazepine, lamotrigine, ethosuxim ide, and phenobarbital), and some nonsteroidal
anti-inflammatory drugs ( especially piroxicam). This patient initially presented with a urinary tract infection, and her primary
care physician likely prescribed trimethoprim-sulfamethoxazole (TMP-SMX), which is a sulfonamide notorious for inducing
drug reaction. Her presentation is not extensive enough ito be described TEN, as it generally involves detachment of >30
percent of the body surface area .
Urinary tract infection Toxic epidermal necrolysis Ethosuximide Carbamazepine lamotrigine Sulfonamide (medicine) Phenobarbital Allopurinol Erythema multiforme Piroxicam
Trimethoprim/sulfamethoxazole Erythema Sulfonamide Prodrome Anticonvulsant Nonsteroidal anti-inflammatory drug Necrosis Rash Toxicity Epidermis Anti-inflammatory Fever
Pharmaceutical drug
E i s not correct. SO/o c hose th is.

Toxic shock syndrome (TSS) is caused by the Staphylococcus aureus exotoxin, toxic shock syndrome toxin-1 (TSST-1 ) . TSST-
1 is a superantigen capable of activating large populations ofT lymphocytes, resu lt ing in massive cytokine release that leads
to fever, nausea/ vomit ing, hypotension, and skin manifestations. Patients with TSS develop diffuse erythematous patches and
often the rash is present on the palms and soles . In more severe cases petechiae, vesicles, bu llae, and skin ulcerations with
desquamation may develop . TSS usually develops either acutely in women with in days of menstruation, or in both genders
related to surgica l or nonsurgical wounds ( eg, burns and skin lacerations), none of which apply to the patient described in the
v ignette. The patient is also not suffering from any signs or symptoms of shock . •
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p • •y
Urinary tract infection Toxic epidermal necrolysis Ethosuximide Carbamazepine lamotrigine Sulfonamide (medicine) Phenobarbital Allopurinol Erythema multifonme Piroxicam
2
Trimethoprim/sulfamethoxazole Erythema Sulfonamide Prodrome Anticonvulsant Nonsteroidal anti-inflammatory drug Necrosis Rash Toxicity Epidenmis Anti-inflammatory Fever
3
Pharmaceutical drug
4
•5 E is not correct. SOlo chose this .
•6 Toxic shock syndrome (TSS) is caused by the Staphylococcus aureus exotoxin, toxic shock syndrome toxin-! (TSST-1 ) . TSST-
•7
1 is a superantigen capable of activating large populations ofT lymphocytes, resulting in massive cytokine release that leads
to fever, nausea/ vomiting, hypotension, and skin manifestations. Patients with TSS develop diffuse erythematous patches and
often the rash is present on the palms and soles. In more severe cases petechiae, vesicles, bul lae, and skin ulcerations with
desquamation may develop . TSS usually develops either acutely in women within days of menstruation, or in both genders
related to su rgica l or nonsurgical wounds ( eg, burns and skin lacerations), none of which apply to the patient described in the
v ignette. The patient is also not suffering from any signs or symptoms of shock .
Superantigen Toxic shock syndrome Cytokine Staphylococcus au reus Exotoxin Desquamation Petechia Hypotension Staphylococcus Menstruation Erythema lymphocyte T cell
Cutaneous condition Rash Fever Blister
Bottom line:
Stevens-Johnson syndrome is a type of erythema multiforme general ly preceded by a prodrome before the onset of
mucocutaneous lesions. Patients develop a characteristi c rash, palpable pu rpura, skin necrosis, bulla formation, and
sloughing of the skin involving < 10% of the body surface ar ea . It is commonly precipitated by med ications, including
trimethoprim-su lfamethoxazole.
Stevens-Johnson syndrome Erythema multiforme Erythema Trimethoprim/sulfamethoxazole Prodrome Necrosis Purpura Rash Body surface area
References:
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A previously healthy 28-year-old man comes to his primary care physician because of the sudden appearance of multiple
2 sma ll, pruritic lesions over his trunk one week after a larger lesion appeared. The patient is a monk who has lived in a
3 monastery for the past 11 years. He has no known medic.al history and he denies ever having been sexua lly active .
4 Physical examination reveals erythematous, scaly and ring-shaped lesions on his back that li ne up along the ribs (see image),
no lesions are present on the palmar or plantar surfaces .
•5
•6
r------------------------------,
•7
What exclusionary diagnostic test shou ld be ordered prior to making a diagnosis?
A. No further testing is warranted

B. Potassium hydroxide (KOH) test
C. Radioallergosorbent assay testing
D. Rapid plasma reagin testing
E. Skin biopsy
F. Visua lization under a Wood's lamp
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monastery for the past 11 years. He has no known medic.al history and he denies ever having been sexually active .
. -
2 Physical examination reveals erythematous, sca ly and ring-shaped lesions on his back that line up along the ribs (see image),
3 no lesions are present on the pa lmar or plantar surfaces.
4 r---------------------------~
•5
•6
•7
What exclusionary diagnostic test should be ordered prior to making a diagnosis?
A. No further testing is warranted

B. Potassium hydroxide (KOH) test
C. Radioallergosorbent assay testing
D. Rapid plasma reagin testing
E. Skin biopsy
F. Visualization under a Wood's lamp
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2 The correct answer is A. 36% chose this.

3 This patient most likely has pity riasis rosea. This rash has unclear etiology, but it most likely represents a viral exanthema
4
(H HV-7) . It is self-limited and usual ly resolves within 1 month . This rash has multiple unique characteristics, including the
appearance of a "herald patch," a single larger lesion, approximately 1 week prior to the eruption of multiple lesions covering
5 the trunk in a "Christmas tree" distribution . About 75% of patients will present with pruritus as the chief complaint. The
•6 diagnosis of pityriasis rosea is made cli nically.
•7 Pityriasis rosea Itch Exanthem Etiology Rash Virus Pityriasis

Potassium hydroxide (KOH) test may be warranted when only the herald patch is present before the onset of multiple smaller
lesions in the classic "Christmas tree" distribution . Tinea infections do not present abruptly as in th is patient, other clues to
the possibility of a t inea infection include onychomycosis and an intertriginous location of the rash.
Potassium hydroxide Onychomycosis Intertriginous Intertrigo Tinea Potassium Rash Infection
C is not correct. 5% chose this.

This patient has no history of recent skin exposure to new or unknown elements so radioallergosorbent assay testing is not
warranted at th is stage. Also, it is not critical that urticaria is ruled out in this patient. It is more im portant that a diagnosis of
syph ilis not be m issed .
Syphilis Urticaria
D is not correct. 90/o chose this.

This patient most likely has pityriasis rosea. This rash has unclear etiology, but it most likely represents a viral exanthema
(H HV-7) . It is self-limited and usual ly resolves within 1 month . This rash has multiple unique characteristics, including the
appearance of a " herald patch," a single larger lesion, approximately 1 week prior to the eruption of multiple lesions covering
the trunk in a "Christmas tree" distribution . About 75% of patients will present with pruritus as the chief complaint. The
diagnosis of pityriasis rosea is made cli nically. When the classic presentation is absent and the patient is sexually active,
secondary syphilis is in the differentia l; however, the rash is nonpruritic and may also present with fever, lymphadenopathy,
condylomata lata, palmar rash, and hair loss, all of wh ich are absent in our patient.
Itch Condylomata lata Pityriasis rosea Syphilis Lymphadenopathy Secondary syphilis Hair loss Exanthem Genital wart Etiology Pityriasis Lesion Fever Rash Virus
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1 syphilis not be missed .

Syphilis Urticaria
2
3 D is not correct. 90/o chose this.
4 This patient most likely has pityriasis rosea . This rash has unclear etiology, but it most likely represents a viral exanthema
5 (HHV-7) . It is self-limited and usually resolves within 1 month . This rash has multiple unique characteristics, including the
appea rance of a "herald patch," a single larger lesion, approximately 1 week prior to the eruption of multiple lesions covering
•6
the trunk in a "Christmas tree" distribution . About 75% of patients will present with pruritus as the chief complaint. The
•7 diagnosis of pityriasis rosea is made clinically. When the classic presentation is absent and the patient is sexually active,
secondary syphilis is in the differentia l; however, the rash is nonpruritic and may also present with fever, lymphadenopathy,
condylomata lata, palmar rash, and hair loss, all of wh ich are absent in our patient.

Skin biopsy is often the gold standard for diagnosis of a variety of skin conditions, particularly skin cancers. Because the
lesions of pityriasis are so characteristic, and because the disease is self· lim iting, the morbidity of skin biopsy outweighs any
potential diagnostic advantage it might offer.
Biopsy Skin biopsy Gold standard (test)
F is not correct. 150/o chose this.

Visualization of rashes under ultraviolet light at a specific wavelength is known as Wood's lamp technique . The subsequent
fluorescence from a variety of skin conditions may help distinguish fungal infections, particularly those on hard-to-see areas,
such as the scalp, from other sources . It can also be used in the diagnosis of ethylene glycol poisoning, tuberous sclerosis,
and erythrasma . Ultraviolet light examination is not indicated for pityriasis rosea.
Wood's lamp Erythrasma Tuberous sclerosis Ethylene glycol Ethylene glycol poisoning Pityriasis rosea Ultraviolet Fluorescence Ethylene Wavelength Mycosis Fungus
Bottom Line:
The diagnosis of pityriasis rosea is made clinically with ti:he characteristic herald patch preceding the onset of multiple
smaller lesions in a "Christmas tree" distribution. and the absence of svmotoms other than oruritis. Seroloaic testina to rule
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1 • ry yp • 1 p • 1 y p 1 y p • p y,
condylomata lata, palmar rash, and hair loss, all of which are absent in our patient.
2
3
4
E is not correct. 6 0/o c hose th is.
Skin biopsy is often the gold standard for diagnosis of a variety of skin cond it ions, particu larly skin cancers. Because the
5
lesions of pityriasis are so characteristic, and because the disease is self- limiting, the morbidity of skin biopsy outweighs any
•6 potential diagnostic advantage it might offer.
•7 Biopsy Skin biopsy Gold standard (test)
F is not correct. 150/o chose th is.

Visualization of rashes under ultraviolet light at a specific wavelength is known as Wood's lamp technique . The subsequent
fluorescence from a variety of skin conditions may help distinguish fungal infections, particularly those on hard-to-see areas,
such as the scalp, from other sources . It can also be used in the diagnosis of ethylene glycol poisoning, tuberous sclerosis,
and erythrasma . Ultraviolet light examination is not indicated for pityriasis rosea .
Wood's lamp Erythrasma Tuberous sderosis Ethylene glycol Ethylene glycol poisoning Pityriasis rosea Ultraviolet Fluorescence Ethylene Wavelength Mycosis Fungus
Bottom line :
The diagnosis of pityriasis rosea is made clinically with 1the characteristic herald patch preceding the onset of mu lt iple
smaller lesions in a "Christmas tree" distribution, and the absence of symptoms other than pruritis. Serologic testing to rule
out syphilis for sexually active patients and potassium hydroxide (KOH) test to rule out tinea is recommended when the
presentation is atypical.
Potassium hydroxide Pityriasis rosea Syphilis Itch Tinea Potassium
References:
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A 25-year-old man comes to his primary care physician complaining of a rash on his shins . The patient says that the rash ~~AI
2 does not itch, and he thinks that he had a similar rash about 3 months ago that went away w ithout intervention . Physical
3 examination reveals sharply defined erythematous plaques with silvery micaceous scale involv ing the anterior tibial area
4 bilatera lly. The total body surface area involved is < 5% . He denies j oint pain or stiffness . The young man expresses concern
over the cosmetic appearance of his legs and asks for treatment.
5 ........--- - - - - - ;-...;
•6
•7
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2
3
4
5
•6
•7
Which of the following therapy types is indicated for his dermatologic condition at th is time"
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Which of the following therapy types is indicated for his dermatologic condition at this time?
A. Etanercept
B . Methotrexate
C. Oral corticosteroids
D . Topical corticosteroid
E. Ultraviolet radiation
a
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Item: 6 of 7 ~ 1 • Mark -<] C> Jill ~- ~J
2 The correct answer is D. 570/o chose this.

3 This patient is experiencing mild plaque psoriasis based on his presentation and as illustrated in the image . Psoriasis is
4
generally characterized by epidermal hyperplasia with pa,rakeratotic sca ling and inflammatory cell infiltrate, especially T
lymphocytes. In itial therapy for psoriasis includes m id-potency to strong potency steroids ( in order of increasing potency),
5 including hydrocortisone, triamcinolone, fluocinonide, betamethasone, and clobetasol. Additional topical therapies include tar,
6 anthra li n, calcipotriene, or retinoids . These agents are often used in alternating weekly treatments with topical steroids to
•7 reduce the side effects of steroid atrophy, striae, and telangiectasia . In addition to steroid treatment, patients with psoriasis
should be counseled to use emollients (ie, petroleum jelly) immediately following a shower or bath . Keeping the affected area
moist helps decrease tenderness and itching . Phototherapy with narrow-band ultraviolet radiation or psoralen with ultraviolet
radiation (PUVA) can be helpfu l when the disease is recalcitrant to topical therapies. Finally, system ic agents, such as
methotrexate and cyclosporine, or biolog ic agents (such as anti-TNF inhibitors) can be used for patients w ith extensive or
recalcitrant disease .
Fluocinonide Psoralen Methotrexate Cortisol Psoriasis Ciclosporin Light therapy Betamethasone Clobetasol propionate Triamcinolone Itch Epidermis PUVA therapy Petroleum jelly
Dithranol Retinoid Calcipotriol T cell Telangiectasia Ultraviolet Lymphocyte White alood cell Parakeratosis TNF inhibitor Acanthosis Moisturizer Steroid Atrophy Hyperplasia
Inflammation Drug Topical steroid
A is not correct. 100/o chose this.

Etanercept is an anti-tumor necrosis factor (anti-TNF) inhibitor that is commonly prescribed in adults for the treatment of
moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis . It is administered as a subcutaneous
injection and potential adverse effects include reactivation of tuberculosis infection, viral hepatitis B or C, or increased risk of
other infections. This patient does not qualify for treatment with biologic therapy, as his psoriasis is limited to <5% of his
body surface area .
Ankylosing spondylitis Psoriatic arthritis Etanercept Psoriasis Subcutaneous injection Tuberculosis Hepatitis B TNF inhibitor Biopharmaceutical Hepatitis Viral hepatitis Necrosis
Chemotherapy Arthritis Virus Subcutaneous tissue
B is not correct. SO/o chose this.

Methotrexate is a systemic medication used to treat psoriasis. I t should be used only in severe cases of refractive disease or
in thP ~Pttinn nf n~nrir1tir: <'lrthriti~ . ArlvPr~P rln1C"J pffpr:t~ nf thi~ mPrlir:<'ltinn inr:hJrlP thP ri~k nf hPni'ltntmdr:itv. Thi~ n<'ltiPnt rlnP~
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1 body surface area .

2 Ankylosing spondylitis Psoriatic arthritis Etanercept Psoriasis Subcutaneous injection Tuberculosis Hepatitis B TNF inhibitor Biopharmaceutical Hepatitis Viral hepatitis Necrosis
3 Chemotherapy Arthritis Virus Subcutaneous tissue
4 B is not correct. 80/o chose this.

5 Methotrexate is a systemic medication used to treat psor iasis. It should be used only in severe cases of refractive disease or
6 in the setting of psoriatic arthritis. Adverse drug effects of this medication include the risk of hepatotoxicity. This patient does
•7 not qualify for treatment with systemic medication .
Psoriatic arthritis Methotrexate Psoriasis Hepatotoxicity Arthritis Pharmaceutical drug
C is not correct. 70/o chose this.

Oral corticosteroids are not appropriate given this patient's skin findings . Oral corticosteroids can lead to systemic side effects
such as striae, buffalo hump, psychosis, poor wound healing, and immunosuppression . Oral corticosteroids would be
appropriate in a more severe autoimmune disease.
Autoimmune disease Immunosuppression Corticosteroid Psychosis Autoimmunity Wound healing Adverse drug reaction Lipodystrophy Side effect
E is not correct. 18% chose this.

While ultraviolet radiation has been proven to be beneficial in treating psoriasis, its use should be reserved for the treatment
of severe or refractory psoriasis . Ultraviolet radiation may aid in the treatment of psoriasis by slowing keratinization and by
acting as an anti-inflammatory by promoting apoptosis in T cells. Phototherapy is reserved for use by dermatologists and may
increase the risk of cutaneous malignancy.
Psoriasis Apoptosis Light therapy Ultraviolet Keratinization T cell Anti-inflammatory Malignancy Dermatology Cancer Radiation
Bottom line:
Mild psoriasis (sharply defined erythematous papules and plaques on extensor surfaces) is typically treated with topical
corticosteroids, such as betamethasone.
Psoriasis Betamethasone Corticosteroid Erythema Papule
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• I I • • • I I ...
1
Methotrexate is a systemic medication used to treat psoriasis. It should be used only in severe cases of refractive disease or
2
in the setting of psoriatic arthritis. Adverse drug effects of this medication include the risk of hepatotoxicity. This patient does
3 not qualify for treatment with systemic medication.
4 Psoriatic arthritis Methotrexate Psoriasis Hepatotoxicity Arthritis Pharmaceutical drug
5 C is not correct. 7 0/o chos e this .

6 Oral corticosteroids are not appropriate given this patient's skin findings . Oral corticosteroids can lead to systemic side effects
•7 such as striae, buffalo hump, psychosis, poor wound healing, and immunosuppression . Oral corticosteroids would be
appropriate in a more severe autoimmune disease.
Autoimmune disease Immunosuppression Corticosteroid Psychosis Autoimmunity Wound healing Adverse drug reaction Lipodystrophy Side effect
E is not correct. 18% chos e this .

While ultraviolet radiation has been proven to be beneficial in treating psoriasis, its use should be reserved for the treatment
of severe or refractory psoriasis . Ultraviolet radiation may aid in the treatment of psoriasis by slowing keratinization and by
acting as an anti-inflammatory by promoting apoptosis in T cells. Phototherapy is reserved for use by dermatolog ists and may
increase the risk of cutaneous malignancy.
Psoriasis Apoptosis Light therapy Ultraviolet Keratinization T cell Anti-inflammatory Malignancy Dermatology Cancer Radiation
Bottom line :
Mild psoriasis {sharply defined erythematous papules and plaques on extensor surfaces) is typically treated with topical
corticosteroids, such as betamethasone.
Psoriasis Betamethasone Corticosteroid Erythema Papule
References:
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1
A 72-year-old woman comes to the physician because of chron ic blistering on her arms and thighs . The lesions began as ~~AI
2 erythematous, papu lar lesions and progressed to tense, pruritic bullae f illed with serous fluid. Physical examination reveals
3 deep, subepidermal bullae that do not separate from the epidermis when sliding pressure is applied . Biopsy with
4 immunostaining reveals fluorescence at the dermal-epidermal junction .
5
6 Which of the following is the most likely diagnosis?
•7
A. Bu llous pemph igoid
B. Dermatitis herpetiformis
C. Erythema multiforme
D. Pemphigus vulgaris
E. Stevens-Johnson syndrome
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2
The correct answer i s A. 8 30/o chose this .
3
Bullous pemphigoid is an autoimmune disease typica lly seen in patients >60 years old . It is characterized by chron ic, pruritic
4
blistering eruptions on the skin. The tense, serous bullae are Nikolsky's sign- negative (they do not separate from the
5 epidermis when sliding pressure is applied) . The pathogenesis is due to autoantibodies to BPl and BP2 antigens in the
6 basement membrane. It is typica lly seen on the upper arms and th ighs and rarely involves mucous membranes. Biopsy with
7
immunostaining reveals fluorescence for the autoantibod ies at the basement membrane (the dermal-epidermal j unction).
Treatment consists of topical steroids and anti-inflammatories for m ild cases and oral steroids and systemic
immunosuppressants if severe .
Bullous pemphigoid Autoimmune disease Basement membrane Epidermis Biopsy Immunosuppression Immunosuppressive drug Anti-inflammatory Autoantibody Cutaneous condition
Itch Autoimmunity Pathogenesis Antigen Mucous membrane Steroid Blister Dermoepidermal junction
B is not correct. 2 0/o chose this .

Dermatitis herpet iformis is an autoimmune blistering disease that is associated w ith celiac disease. The pathogenesis is due
to IgA deposits in dermal papillae. Blistering is typica lly seen on the elbows, knees, shoulders, and posterior neck. Treatment
with dapsone will cause qu ick resolution of lesions .
Dermatitis herpetiform is Coeliac disease Dapsone Dermal papillae Dermatitis Immunoglobulin A Autoimmunity Autoimmune disease Pathogenesis Dermis
Cis not correct. 1 0/o chose this.

Erythema multiforme is an immune- mediated skin disorder that is caused by drugs (penici llin, sulfonamides, and phenytoin),
infection (especially herpes simplex virus and Mycoplasma), vaccination, or malignancy. Lesions are typically seen on the
extremities and involve < 10% of the body surface, and typically do not involve the mucous membranes . The appearance of
these lesions is different than those described in the vignette. They are typically raised, erythematous plaques that expand to
form target lesions. Biopsy would show perivascular lymphocytes and necrotic keratinocytes.
Phenytoin Erythema multiforme Penicillin Erythema Herpes simplex virus Sulfonamide (medicine) Lymphocyte Biopsy Immune system Autoimmunity Cutaneous condition
Herpes simplex Mycoplasma Keratinocyte Necrosis Malignancy Sulfonamide Virus Mucous membrane Cancer Vaccination Infection Smooth muscle tissue
D i s not correct. 1 30/o chose this.
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QID: 24221 ..1 Previous Next Lab'V!I!ues
Notes Calculator
............ "' ... . ...... . . . . . . . . .. . . "' ......... .
1
2 D i s not correct. 1 30/o chose t his.

3 Pemphigus vulgaris is an autoimmune disease characterized by chronic blistering and erosions; however, the blisters and
erosions are shallow (intraepidermal), painful, and may involve mucous membranes . They are Nikolsky's sign- positive. The
4
pathogenesis is due to autoantibod ies against desmocollins and desmogleins in the epidermal keratinocytes .
5 Pemphigus vulgaris Autoimmune disease Autoantibody Pemphigus Desmoglein Desmocollin Autoimmunity Keratinocyte Pathogenesis Epidermis Mucous membrane
6
E i s n ot correct. 1 0/o c hose th is.
7
Stevens-Johnson syndrome exists on a continuum with e·rythema multiforme and toxic epidermal necrolysis. Stevens-Johnson
syndrome is a life-threatening exfoliative skin condit ion that also involves the mucous membranes. It typically presents with a
flu-like syndrome, skin tenderness, and painfu l lesions on the skin and mouth. The blisters are Nikolsky's sign-posit ive . Skin
biopsy wou ld reveal a perivascular mononuclear infiltrate and degenerated basal cells . Treatment involves early diagnosis,
removing the offending agent, analgesia, and intravenous immune globulin . Prevention of superinfection w ith bacteria and
excess fluid loss is essential.
Toxic epidermal necrolysis Stevens-Johnson syndrome Erythema multiforme Erythema Analgesic Mucous membrane Biopsy Skin biopsy Intravenous therapy Epidermis Bacteria
Superinfection Stratum basale Cutaneous condition Antibody Influenza-like illness Toxicity
Bottom Line :
Bullous pemphigoid is an autoimmune disease characte1rized by chronic, pruritic blistering eruptions on the skin that do not
separate from the epidermis when sliding pressure is applied . Biopsy with immunostain ing reveals fluorescence at the
dermal-epidermal junction.
Bullous pemphigoid Autoimmune disease Epidermis Biopsy Cutaneous condition Autoimmunity Itch Dermoepidermal junction
References:
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Item: 1 of 7 ~ 1 • Mark -<] C> Jill ~· ~J

QID: 24313 ..1 Previous Next Lab'V!I!ues Notes Calculator

A. Macu les, papules, vesicles, and targetoid lesions

Cutaneous condition Gastrointestinal tract Ascending cholangitis Pyoderma

A is not correct. 8% chose this.

1 Cutaneous condition Gastrointestinal tract Ascending cholangitis Pyoderma

Infection Blood vessel Gastrointestinal tract

B is not correct. 150/o chose this.

Desmoglein Oral mucosa Serum (blood) Gastrointestinal tract Inflammation

C is not correct. 150/o chose this.

E is not correct. 30/o chose this.

•3 Desmoglein Oral mucosa Serum (blood) Gastrointestinal tract Inflammation

•4 C is not correct. 150/o chose this.

E is not correct. 30/o chose this.

Mucous membrane Oral mucosa Epidermis Pemphigoid Gastrointestinal tract Inflammation

Which of the following is the most appropriate treatment?

2 The correct answer is E. 73% chose this.

A is not correct. SOfo chose this.

B is not correct. 100/o chose this.

C is not correct. SOfo chose this.

D is not correct. 4% chose this.

Which of the following is the most likely diagnosis?

Actinic elastosis Carcinoma Scalp Papule Squamous epithelial cell Sandpaper

B is not correct. 120/o chose this.

C is not correct. 3% chose this.

D is not correct. 100/o chose this.

•4 D is not correct. 100/o chose this .

E is not correct. 16% c hos e this .

Metastasis United States

What is the most likely cause of this patient's presentation?

B. Scalded skin syndrome

2 The correct answer is C. 730/o chose this.

A is not correct. 5% chose this.

B is not correct. 60/o chose this.

2 B is not correct. 6 0/o chose this.

E i s not correct. SO/o c hose th is.

Cutaneous condition Rash Fever Blister

What exclusionary diagnostic test shou ld be ordered prior to making a diagnosis?

A. No further testing is warranted

What exclusionary diagnostic test should be ordered prior to making a diagnosis?

A. No further testing is warranted

2 The correct answer is A. 36% chose this.

B is not correct. 290/o chose this.

C is not correct. 5% chose this.

D is not correct. 90/o chose this.

1 syphilis not be missed .

E is not correct. 60/o chose this.

F is not correct. 150/o chose this.

F is not correct. 150/o chose th is.

2 The correct answer is D. 570/o chose this.

Inflammation Drug Topical steroid

A is not correct. 100/o chose this.

Chemotherapy Arthritis Virus Subcutaneous tissue

B is not correct. SO/o chose this.

1 body surface area .

3 Chemotherapy Arthritis Virus Subcutaneous tissue

4 B is not correct. 80/o chose this.

C is not correct. 70/o chose this.

E is not correct. 18% chose this.

5 C is not correct. 7 0/o chos e this .

E is not correct. 18% chos e this .

B is not correct. 2 0/o chose this .